Provider Demographics
NPI:1558558767
Name:WENTZVILLE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:WENTZVILLE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WILMES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:636-332-2050
Mailing Address - Street 1:20 WENTZVILLE MARKET PL
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4430
Mailing Address - Country:US
Mailing Address - Phone:636-332-2050
Mailing Address - Fax:636-327-3999
Practice Address - Street 1:20 WENTZVILLE MARKET PL
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-4430
Practice Address - Country:US
Practice Address - Phone:636-332-2050
Practice Address - Fax:636-327-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001012908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty